First Breath Program 2015 Annual Report

First Breath Program 2015 Annual Report The First Breath program has been so instrumental in my journey, the support and resources that they have provided have truly been a blessing. I can't thank them enough for everything they have done. -First Breath Participant Perinatal Smoking Cessation Services Provided: January 1, 2015-December 31, 2015

First Breath 2015 Annual Report Services Provided January 1, 2015 to December 31, 2015 Wisconsin Women s Health Foundation 2503 Todd Drive Madison, WI 53713 Phone: 1-800-448-5148 Fax: 608-251-4136 Email: fbmbm@wwhf.org Page 2 of 30

Table of Contents 1. Executive Summary 2. First Breath Background A. Mission B. Description C. Goals D. Objectives E. Providers and Sites F. Participation G. Funding 3. First Breath Site and Provider Outcomes A. New Site and Provider Training B. Refresher Training C. Continuing Education i. Annual Perinatal Programs Statewide Meeting ii. Regional Practice Session iii. Webinar Training Opportunities iv. E-Newsletters 4. First Breath Participation A. First Breath Enrollment B. Support Program Enrollment i. Text.Connect.Quit ii. Striving To Quit 5. First Breath Participant Outcomes A. Data Collection B. Demographics C. Social Support, Mood, and Stress D. Tobacco Use History E. Smoking Cessation Goals F. Smoking Behavior During First Breath G. Group Differences in Self-Report Smoking Information H. Harm Reduction I. Quit/Cut Down Rates J. Delivery Outcomes K. Participant Experience Survey 6. Appendix A. First Breath Enrollment by Site 7. Appendix B. First Breath Refresher Training Menu 2015 Page 3 of 30

1. Executive Summary First Breath is a smoking cessation program for pregnant women in Wisconsin. Participating women receive evidence-based counseling services, education, and support as part of their regular prenatal services with a First Breath provider. First Breath is currently offered at 158 health care settings serving 65 of Wisconsin s 72 counties. In 2015, 1,752 women received smoking cessation counseling from a First Breath provider. 83% of participants were either able to quit or significantly cut back on their tobacco use during their pregnancy. 2015 was also a year of improvement. We surpassed the 17,000 th woman enrolling into the program. Our Statewide Meeting and Regional Practice Sessions received their highest satisfaction ratings to date. We also made significant updates to our Text.Connect.Quit program, allowing for a more streamlined process and greater interaction between staff and program participants via text message. First Breath Participants A total of 1,752 women received First Breath program services in 2015 o 1,263 women enrolled into First Breath 609 of these women expressed interest in a text message support program (Text.Connect.Quit) o 489 women enrolled into First Breath in 2014, but completed a prenatal or postpartum follow up in 2015 83% of participants abstained, quit, or cut back on their tobacco use while pregnant o 35% remained smoke-free or quit o 48% reduced their tobacco usage First Breath Sites 158 sites participated in the program 18 new sites were established 126 established sites received specialized training and education Perinatal Provider Education 559 providers participated in an onsite training o 281 providers joined First Breath in 2015 o 278 previously trained providers attended a training 69 providers attended the Statewide Meeting training 132 providers attended the Regional Practice Sessions 2015 Participating Counties Page 4 of 30

2. First Breath Background Mission The mission of First Breath is to improve maternal and child health in Wisconsin through perinatal tobacco cessation programming. Program Description First Breath is a program that helps Wisconsin women quit or reduce smoking by training health care providers to deliver evidence-based tobacco cessation counseling as part of existing prenatal care. The program offers non-judgmental, client-centered counseling, support, educational materials, and meaningful incentives. Program Goals 1. Help pregnant women quit smoking. 2. Reduce smoking among pregnant women who are not able to quit. 3. Improve the health of women and newborns. 4. Decrease the rate of tobacco relapse among mothers after delivery. Program Objectives The First Breath program services are designed to: 1. Help participants quit or significantly reduce their tobacco use throughout the perinatal period; 2. Provide comprehensive tobacco-related training and technical assistance to health care providers; and 3. Disseminate the best practices in maternal smoking research, resources, tools, and continuing education opportunities. First Breath Providers and Sites As of December 31 st, 2015, there were a total of 966 trained First Breath providers active at 158 First Breath sites throughout Wisconsin. See Appendix A for First Breath coverage by county. First Breath Providers First Breath providers are individual health care providers that have completed the initial First Breath training and implement the program. They include, but are not limited to: Registered Nurses Nurse Practitioners Certified Nursing Assistants Licensed Practical Nurses Midwives Case/Care Managers Physician s Assistants Social Workers Nutritionists Outreach Specialists Community Health Workers Respiratory Therapists Physicians Psychologists Page 5 of 30

First Breath Sites First Breath sites are trained agencies that offer the First Breath program. They include, but are not limited to: Prenatal Care Coordination Programs (PNCC) Public Health Departments Women, Infants and Children (WIC) Offices Home Visitation Federally Qualified Health Centers Indian Health Services Health Maintenance Organizations (HMOs) Obstetric Practices Family Practice Primary Care Clinics Behavioral Health Clinics Community Service Agencies Community Health Center Program Participation To date, 17,356 women have participated in the First Breath program since 2000. Any pregnant woman in Wisconsin who currently smokes or who has smoked regularly in the last six months is eligible to participate. Women who participate in the First Breath program receive: Individualized smoking cessation counseling from a trained health care provider Educational and self-help materials Educational materials for their friends and family Participation incentives A gift at delivery Wisconsin Tobacco Quit Line information and materials Optional participation in support programs, such as: text messaging and information/tips through our Facebook page Funding In 2015, First Breath received funding from the State of Wisconsin Tobacco Prevention and Control Program. Additionally, in partnership with the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI), and the Wisconsin Department of Health Services (DHS), First Breath participated in the STQ study funded by the Centers for Medicare and Medicaid Services. Striving to Quit helped to support First Breath program expansion and evaluation. First Breath was also supported through additional funding through the Department of Health Services Maternal and Child Health Program, as well as by the March of Dimes (Anthem Foundation) and the UW School of Medicine and Public Health from the Wisconsin Partnership Program.

3. First Breath Sites & Provider Outcomes One of the main objectives of the First Breath program is to provide comprehensive tobacco-related training and technical assistance to prenatal health care providers in Wisconsin. This is accomplished through two types of provider training: new training (for providers and agencies that are new to the First Breath program) and refresher trainings (for previously trained First Breath providers and established sites). In 2015, we trained in 281 new providers at previously existing sites and 18 new sites throughout the state of Wisconsin. 2015 Participating Counties The blue fill on the map to the right shows every county that had at least one First Breath site operating within its borders in 2015. Throughout the year, 158 sites in 65 counties participated in the First Breath program. New First Breath Site and Provider Training In 2015, 281 new First Breath providers were trained at previously existing sites and 18 new First Breath sites were established throughout Wisconsin. The new provider/site training covers content including the need for First Breath, step-by-step program procedures, smoking cessation counseling techniques (5A s, motivational interviewing), case study videos, and how to successfully integrate First Breath into existing services. A First Breath provider manual was provided to each of the new providers. A pre and post training evaluation was administered to measure provider knowledge and readiness to implement the program. Upon completion of the initial First Breath training: 97% of new providers reported feeling ready to implement First Breath 98% demonstrated an increase in knowledge around perinatal tobacco cessation First Breath Refresher Training In 2015, 278 previously trained First Breath providers at 126 established sites participated in a refresher training. This means that 90% of existing First Breath sites participated in a training event. Providers were given several refresher training options in 2015. Please see Appendix B for a full list of refresher training content options. Pre- and post-training evaluations were administered to measure increases in our central First Breath provider measurements: provider knowledge and readiness to implement the program. Upon completion of the refresher training: 98% felt the training was useful to them as a prenatal care provider. 93% demonstrated an increase in knowledge around perinatal tobacco cessation. Page 7 of 30

Continuing Education Opportunities The First Breath program aims to disseminate evidence-based best practices in maternal smoking research, resources, and tools through a variety of continuing education opportunities. Four events/activities were held throughout 2015: Annual Perinatal Programs Statewide Meeting Regional Practice Sessions Webinar on poverty and tobacco use among pregnant women Webinar on perinatal oral health and tobacco In addition to these activities, providers also received information and education through our monthly E-newsletter. Annual Perinatal Programs Statewide Meeting The Perinatal Programs Statewide Meeting is held annually to provide an opportunity for providers and partners from throughout the state to come together for a day of shared learning and networking. Experts are invited to present on a variety of topics pertinent to perinatal tobacco cessation. The 2015 Perinatal Programs Statewide Meeting was themed Familiar Story, Fresh Outlook: Addressing Social and Behavioral Factors in Perinatal Tobacco & Alcohol Use and was held in Rothschild, Wisconsin on Thursday, March 12 th. The Perinatal Programs Statewide Meeting was a tremendous success in terms of quality and satisfaction. 69 First Breath providers participated in the event, which exceeded our estimation based on location. On the evaluation of the event: 100% agreed that the meeting provided them with information that they could use 100% agreed that they learned new skills to use with their patients, and 100% agreed that the meeting was a valuable use of their time 2015 Statewide Meeting Keynote Session 2015 Statewide Meeting Group Photo Page 8 of 30

Regional Practice Sessions Regional Practice Sessions (RPS) are held annually to disseminate information and provide an opportunity for discussion and skill development among First Breath sites in five different regions. RPS were held in Madison (September 29 th ), Milwaukee (September 30 th ), Appleton (October 1 st ), Eau Claire (October 8 th ), and Hayward (October 9 th ). The theme of the 2015 Regional Practice Sessions was The Significance of Stress. The sessions included presentations on the neurobiology of stress as well as stress management and mindfulness activities for providers to utilize with participants as well as incorporate into their own lives. Providers practicing a body scan mindfulness technique at the Milwaukee RPS 2015 saw record breaking participation for this event. 132 First Breath providers from 60 different sites participated in the 2015 RPS. The evaluations were overwhelming positive, with 99% of providers agreeing the event was a positive use of their time and that they learned new tools they can use with program participants. Webinar Training Opportunities Following the December 30 th webinar, 94% of attendees indicated that the webinar provided them with information they could use and they were glad they attended. On June 10 th, 2015 we partnered with the WI Tobacco Prevention and Poverty network on a webinar focusing on strategies to reach and assist women in poverty who are dealing with tobacco addiction during their pregnancy. Lorraine Lathen co-presented this webinar with Carl Oliver, and 41 providers registered to attend this webinar. On Wednesday, December 30th, we partnered with Dr. Kevin DeGroot, DDS to present a webinar on the topic of Perinatal Oral Health: What Pregnant Women Need to Know. 94 individuals tuned into the live webinar, which received an overwhelmingly positive evaluation. Page 9 of 30

E-Newsletters First Breath published monthly e-newsletters for sites containing program updates, emerging research, highlights of First Breath sites and providers, and promising practices in perinatal tobacco cessation. We also utilized the newsletter to inform providers of new educational materials available through the foundation. This newsletter is also our primary means of advertising upcoming events like the Statewide Meeting or webinar opportunities. New poster made available to First Breath providers through the e-newsletter Page 10 of 30

4. First Breath Participation First Breath Enrollment In 2015, 1,263 women enrolled into the First Breath program. These women received smoking cessation counseling, educational handouts, and small incentives for their participation. Three First Breath participants from 2015 (written consent for photo use obtained) Support Program Enrollment Text.Connect.Quit In 2015, the Text.Connect.Quit (TCQ) program was updated and improved. A change in messaging platform (Mobile Commons) allowed for service expansion. Participants in the text messaging program receive three text messages per week from the date they sign up through six months postpartum. Messages include a blend of educational messages, encouragement, and tips/techniques for quitting and cutting down. Women also have the ability to reply to these messages and engage with program staff in text based conversations. By the end of 2015, 361 women were engaged in the TCQ program. Postpartum Support through Striving To Quit Research Study Eligible First Breath participants who met study requirements were offered voluntary participation in a research study called Striving to Quit. Striving to Quit was funded by Centers for Medicare and Medicaid Services and was conducted in partnership with the Wisconsin Department of Health Services and the UW- Center for Tobacco Research and Intervention. Participants received intensive telephonic and in-person tobacco cessation counseling from delivery to six months postpartum. Study participants also received individualized action plans and incentives. Enrollment ended in May of 2015 and services concluded in December of 2015. In November of 2015, a Community Opportunities Grant from the Wisconsin Partnership Program allowed us to begin providing similar services to women and their support networks in the northwest region of the state. Page 11 of 30

5. First Breath Participant Outcomes Data Collection First Breath participants complete surveys at visits with their providers at three points in the program. These surveys include questions about current tobacco use, past tobacco use, and smoking cessation goals. This data is used to evaluate changes in self-reported smoking behavior during the course of participation in First Breath, as well as relationships between demographic variables, cessation goals, and tobacco use. Data is collected from women at: The enrollment visit - which usually takes place during the second trimester The prenatal follow-up visit - which typically occurs during the third trimester The postpartum visit - which on average, takes place within 60 days after delivery. Enrollment Survey Prenatal Survey Postpartum Survey Participant enrolls into First Breath Participant attends prenatal follow-up visits and completes one Prenatal Follow-Up survey DELIVERY Final First Breath visit Data analysis for the 2015 annual report includes data collected from all participants who enrolled in 2015, as well as data from all Prenatal Follow-Up and Postpartum surveys that were completed in 2015. Therefore, the longitudinal analyses, and some cross-sectional analyses 1, include data from both 2014 and 2015 enrollees. 1 Each set of analyses notes which years of data were included. Page 12 of 30

Demographics Table 1 presents demographic information for the 1,263 women who enrolled in First Breath in 2015. The majority of the 2015 enrollees were between the ages of 18 and 34 at the time of enrollment, with an average age of 26. Most were White (65.2%), had a high school education or lower (62%) and were enrolled in Medicaid (79.4%). Table 1: First Breath Client Demographics 2014 2015 2014 2015 Age # % # % Race # % # % 13-17 37 2.5% 9 1% American Indian/Alaskan Native 64 4.4% 36 2.9% 18-24 574 39.2 476 38 Asian 8 0.5 4 0.3 25-34 722 49.3 636 50 Black or African American 340 23.2 285 22.6 35-44 122 8.3 99 8 Native Hawaiian/Pacific Islander 3 0.2 2 0.2 45 and above 0 0 1 0 White 955 65.2 824 65.2 Unknown 10 0.7 42 3 Multiracial 71 4.8 51 4 Ethnicity # % # % Other 5 0.3 10 0.8 Hispanic/Latina 84 5.7% 84 6.7% Unknown 19 1.3 51 4 Non-Hispanic/Latina 1343 91.7 1130 89.4 Unknown 38 2.6 49 3.9 Education # % # % Employed # % # % Less than high school 63 4.3% 47 3.7% Yes 567 38.7% 563 44.6% Some high school 281 19.2 206 16.3 No 791 54.0 614 48.6 High school or GED 609 41.6 573 45.4 Unknown 107 7.3 86 6.8 Some college/2-yr 405 27.6 350 27.7 Enrolled in Medicaid # % # % College 68 4.6 38 3 Yes 1222 83.4% 1003 79.4% Post-college education 3 0.2 3 0.2 No 240 16.4 260 20.6 Unknown 36 2.5 46 3.6 Page 13 of 30

Social Support, Stress, and Mood Table 2 presents the information about 2015 enrollees self-reported stress, mood, and social support at the enrollment visit. Table 2: Social Support and Well-Being # People to count on (n=1263) # % Relationship status (n=1263) # % 0 23 2% Single 442 35% 1-2 371 29% In a relationship 385 30.5% 3-5 505 40% Living with a partner 225 17.8% 6+ 228 18% Married 139 11% Unknown 136 11% Widowed 1 0.1% Divorced 14 1.1% Other 6 0.5% Unknown 51 4% Current stress level (n=1263) # % Sadness in the past week (n=1263) # % Low 325 25.7% None 442 35% Medium 528 41.8% Not very often 473 37.5% High 206 16.3% Very often 165 13.1% Very high 88 7.0% Most of the time 70 5.5% Unknown 116 9.2% Unknown 113 8.9% Page 14 of 30

Tobacco Use History Table 3 presents information about participants smoking history. Of the 1,263 women who completed Enrollment forms in 2015: 59.1% (n=746) started smoking between the ages of 13 and 17. 34% (n=429) reported smoking 11 to 20 cigarettes per day (there are 20 cigarettes in one pack), 1 month prior to getting pregnant, and 28.7% (n=362) reported smoking 6-10 cigarettes per day at that time point. 37.5% (n=474) said that, before they were pregnant, they usually had their first cigarette of the day immediately (within five minutes) after waking up, which is a marker of tobacco dependence. 67.4% (n=852) reported they had tried to quit smoking previously. Of the 852 women with previous quit attempts: o 25% had one previous quit attempt; o 30% had two previous quit attempts; o 19% had three previous quit attempts; o 25% had four or more previous quit attempts Table 3: First Breath Clients Smoking History Age started smoking # % Smoking 1 month before pregnancy # % <13 170 13.5% Not smoking 11 0.9% 13-17 746 59.1% A few some days, not every day 30 2.4% 18-24 268 21.2% 1-5 cigarettes/day 234 18.5% 25-36 21 1.7% 6-10 cigarettes/day 362 28.7% Unknown 58 4.6% 11-20 cigarettes/day 429 34.0% Number of quit attempts # % 21-30 cigarettes/day 95 7.5% 0 226 17.9% 31-40 cigarettes/day 41 3.2% 1 212 16.8% >40 cigarettes/day 12 1.0% 2 257 20.3% Unknown 49 3.9% 3 166 13.1% 4 74 5.9% 5 70 5.5% >5 73 5.8% Unknown 185 14.6% Page 15 of 30

Smoking Cessation Goals During the enrollment visit, First Breath providers ask women what they would like to happen with their smoking. Figure 1 shows participants responses to this question. As shown below, nearly all First Breath participants expressed a desire to quit smoking and stay quit. Understanding First Breath participants smoking cessation goals at enrollment helps First Breath Providers adjust program content and quit strategies to fit individual participant needs. First Breath providers also are aware that a woman s quit goals will remain fluid throughout her participation in the program, and just because a woman only wants to cut down during her enrollment visit, she may become more interested in fully quitting as time goes on. Figure 1: Smoking Cessation Goals 1% 5% 4% 5% 6% Quit for good Quit until baby is born Cut down Don't want to quit Don't know what I want Unknown 79% Page 16 of 30

Smoking Behavior During First Breath Women are asked to report how many cigarettes per day they smoked during the past week. Table 5 shows participants responses to this question at each data collection time point during participation in First Breath 2. Figure 2 presents the self-reported smoking rates for these three time points, as well as 1 month prior to learning about the pregnancy. As Figure 2 shows, the majority of First Breath participants were heavy smokers prior to pregnancy. Although many women report quitting smoking or dramatically reducing the amount they smoke when learning of their pregnancy, most women need additional support throughout their pregnancy to stay quit or to quit completely. Table 5: Smoking During First Breath Enrollment (n=1263) Prenatal Follow-Up (n=781) Postpartum (n=802) Not smoking 254 (20%) 277 (35%) 272 (34%) Some, but not every day 116 (9%) 75 (10%) 71 (9%) 1-5 cigarettes/day 378 (30%) 241 (31%) 215 (27%) 6-10 cigarettes/day 289 (23%) 132 (17%) 49 (6%) >10 cigarettes/day 132 (10%) 3 52 (2%) 4 67 (8%) 5 Figure 2: Smoking During First Breath and 1 Month Prior to Pregnancy 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 1 Month Prior to Pregnancy* Enrollment Visit Prenatal Follow-up Postpartum Visit Not smoking Some, but not every day 1-5 cigarettes/day 6-10 cigarettes/day >10 cigarettes/day Not Smoking (alternate view) *The enrollment survey asks women to retroactively report how much they were smoking one month prior to learning they were pregnant. Categories may not add up to 100% due to missing information/unanswered questions. 2 781 women enrolled in either 2014 or 2015 completed Prenatal Follow-Up survey in 2015, and 802 women enrolled in either 2014 or 2015 completed Postpartum Follow-up in 2015. 3 7% of participants (n=94) did not complete the smoking status section of the enrollment survey. 4 1% of participants (n=4) did not complete the smoking status section of the prenatal survey. 5 8% of participants (n=67) did not complete the smoking status section of the postpartum survey. Page 17 of 30

Harm Reduction The ultimate objective of the program is smoking cessation. In addition, First Breath has adopted a harm reduction approach and recognizes that smoking reduction and cessation during pregnancy are beneficial, though not as beneficial as cessation. Harm reduction results are based on the 729 women who have completed both baseline (enrollment survey) and postpartum survey. Figure 3 presents a graph of average self-reported smoking at each time point during their pregnancy. Figure 3: 5.00 4.00 4.38 3.66 3.00 2.00 2.83 2.46 2.44 1.00 1 mo before pregnancy 1st trimester 2nd trimester 3rd trimester Postpartum * Y-axis scale: 1 = not smoking; 2 = smoking a few cigarettes, but not every day; 3 = 1-5 cigarettes/day; 4 = 6-10 cigarettes/day; 5 = 11-20 cigarettes/day Page 18 of 30

Quit Rates & Cut-down Rates Quit rates were caculated for the subsample of the 729 women who have completed the First Breath Program 6 in 2015 for whom we had data at all time points. First Breath smoking rates are self-reported and have not been biologically verified. 249 (34%) women who entered the program reporting smoking one month prior to their pregnancy had quit smoking in the third trimester of their pregnancy. 7 351 (48%) women who entered the program reporting smoking one month prior to their pregnancy had cut down smoking in the third trimester of their pregnancy. Relapse Rate Of the 249 women had quit smoking in the third trimester, 56 (22%) reported smoking again at postpartum visit after their deliveries. Of the 351 women who had cut down in the third trimester, 92 (26%) reported smoking more cigarettes at postpartum visit after their deliveries. Delivery Outcomes 784 postpartum forms submitted in 2015 had delivery outcome information. Of these 784 women: 14% reported premature birth. 11% reported low birth weight (less than 2,500 grams) 2% reported delivering babies with abnormalities. 1% reported stillbirth or infant death. 6 This includes women who enrolled in 2014 but completed the program in 2015. We received Enrollment, Prenatal and Postpartum surveys from these women. 7 This includes 2 women who had quit spontaneously prior to pregnancy and were able to stay quit throughout the pregnancy. Page 19 of 30

Participant Experience Survey In addition to participant outcome data, a participant experience survey was conducted over the phone with a subsample of First Breath participants who had completed the program. This survey consisted of several questions about current tobacco use and satisfaction with the First Breath Program. 30 First Breath Participants completed the survey, and of those: 83.4% agree that First Breath was helpful in their quit attempts 90% said their providers helped them make a quit smoking/stay quit plan When asked what they liked about the program: o Feeling supported by my provider o Getting useful information that helped me quit o Receiving text messages from Text.Connect.Quit I knew that taking this step would not only improve our health, but it would show my daughter that you can do anything you put your mind to-even beating an addiction. Now I have a little extra cash in my pocket [from not buying cigarettes] and I can breathe fresh air and enjoy it; all on top of knowing that I can be a good influence on my baby girl. -First Breath Participant, 2015 Page 20 of 30

6. Appendix A: 2014 First Breath Enrollment by Site SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 ADAMS COUNTY PUBLIC HEALTH ADAM Adams 0 2 3 0 0 1 0 0 0 0 0 0 1 0 5 ASHLAND COUNTY HEALTH & ASHC Ashland 10 9 0 0 0 0 0 0 0 1 0 0 0 0 1 HUMAN SERVICES BARRON COUNTY DHHS BARR Barron 5 7 0 0 1 0 0 0 0 0 1 0 0 0 2 PREGNANCY HELP CENTER PRHC Barron 0 5 0 1 0 0 1 0 0 1 0 0 0 1 4 BAYFIELD COUNTY HEALTH BCHD Bayfield 4 1 0 0 0 0 0 1 0 0 1 1 0 0 3 RED CLIFF COMMUNITY HEALTH RDCF Bayfield 2 5 0 1 1 0 0 0 0 0 0 1 0 0 3 CENTER BROWN COUNTY HEALTH BRCO Brown 2 4 2 0 1 0 0 2 0 1 0 0 1 2 9 CATHOLIC CHARITIES - GREEN CCGB Brown 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BAY DIOCESE DEPERE HEALTH DPHD Brown 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 FAMILY SERVICES OF NORTHEAST FAMS Brown 4 4 0 0 0 0 1 0 0 0 0 0 1 0 2 WI ONEIDA COMMUNITY HEALTH ONEI Brown 14 6 0 0 0 0 1 0 0 1 0 0 0 0 2 CENTER BUFFALO COUNTY DHHS BUFF Buffalo 6 5 0 0 0 1 0 0 0 0 0 0 0 1 2 BURNETT COUNTY DHHS BRNT Burnett 1 5 0 0 0 0 0 0 0 0 0 0 0 0 0 ST. CROIX TRIBAL HEALTH CXTR Burnett 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 CENTER CALUMET COUNTY HEALTH CALU Calumet 4 2 0 0 0 0 0 0 2 0 0 0 0 0 2 CHIPPEWA COUNTY DEPT. OF CHIP Chippewa 23 18 1 1 3 2 0 1 1 0 0 1 1 0 11 PUBLIC HEALTH CLARK COUNTY HEALTH CLAR Clark 2 7 1 0 0 0 0 0 0 1 0 0 0 0 2 COLUMBIA COUNTY DHHS CLMB Columbia 43 36 0 0 5 1 0 2 2 0 1 3 3 0 17 CRAWFORD COUNTY HEALTH CRAW Crawford 2 4 0 0 0 0 0 1 0 0 0 1 0 0 2 GUNDERSEND HEALTH- PRAIRIE GNDP Crawford 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 DU CHIEN ARC CENTER FOR WOMEN AND ARWC Dane 12 11 1 0 2 0 0 0 0 0 2 0 0 0 5 CHILDREN DEAN HEALTH PLAN - STRONG BEGINNINGS DTFB Dane 4 21 4 6 1 3 0 2 2 1 2 3 0 1 25

SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 MADISON WOMEN'S HEALTH MWHC Dane 1 3 1 0 0 0 0 0 0 0 1 0 0 0 2 CLINIC MERITER CENTER FOR MCPC Dane 8 10 0 0 1 1 1 0 0 0 0 0 2 4 9 PERINATAL CARE MERITER DEFOREST WINDSOR MEDF Dane 1 4 0 0 0 0 0 0 0 0 0 0 0 0 0 CLINIC MERITER MCKEE CLINIC MEMK Dane 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MERITER MONONA CLINIC MEMO Dane 1 14 1 0 0 0 1 0 2 0 0 0 0 0 4 PUBLIC HEALTH - MADISON & MDSN Dane 10 16 1 1 0 2 1 1 1 1 1 0 1 1 11 DANE COUNTY UNITY HEALTH INSURANCE UWHI Dane 2 0 0 0 0 1 0 0 0 0 0 0 0 0 1 UW HEALTH 20 S. PARK OB/GYN UWPS Dane 13 13 0 0 0 0 0 1 0 1 0 1 2 0 5 UW HEALTH ARBORETUM UWAR Dane 0 6 0 0 1 1 2 1 2 2 1 2 0 3 15 UW HEALTH EAST CLINIC UWEC Dane 5 2 0 0 1 0 0 0 0 0 0 0 0 0 1 UW HEALTH EAST TOWNE UWET Dane 8 11 1 1 1 0 1 0 1 1 0 1 0 1 8 UW HEALTH FITCHBURG UWFC Dane 8 3 0 0 1 1 2 0 0 0 0 0 1 0 5 UW HEALTH NORTHEAST FAMILY UWNE Dane 1 7 0 0 0 0 0 0 0 2 0 0 0 0 2 MEDICAL CENTER UW HEALTH MIDWIFERY UWMW Dane 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 UW HEALTH SUN PRAIRIE UWSP Dane 13 4 0 1 0 1 1 2 0 1 0 0 0 0 6 UW HEALTH WEST CLINIC UWWC Dane 2 5 0 0 0 0 0 0 0 0 0 0 0 1 1 UW HEALTH WEST TOWNE UWWT Dane 16 8 0 1 0 1 0 1 0 0 1 0 0 0 4 UW HEALTH YAHARA CLINIC UWYC Dane 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 DODGE COUNTY HUMAN DODG Dodge 8 11 1 2 0 1 3 1 1 0 1 0 0 2 12 SERVICES & HEALTH DEPT. DOOR COUNTY PUBLIC HEALTH DOCO Door 18 23 0 1 2 1 3 1 0 0 1 0 0 0 9 NORTHWEST WISCONSIN NWST Douglas 12 13 0 0 0 2 0 0 3 3 0 0 0 1 9 COMMUNITY SERVICE AGENCY WIC DUNN COUNTY HEALTH DUNN Dunn 3 2 0 0 0 0 0 0 0 0 0 0 0 0 0 EAU CLAIRE CITY CO. HEALTH EAUC Eau Claire 18 48 2 2 4 4 3 1 1 2 1 5 7 5 37 Page 22 of 30

SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 GROUP HEALTH COOPERATIVE- EAU CLAIRE UW HEALTH EAU CLAIRE FAMILY MEDICINE CLINIC FOND DU LAC COUNTY HEALTH FOREST COUNTY HEALTH FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER GRANT COUNTY HEALTH NEIGHBORHOOD HEALTH PARTNERS GREEN COUNTY HEALTH GREEN LAKE COUNTY PUBLIC HEALTH DEPT. IOWA COUNTY HEALTH HO-CHUNK HEALTH BLACK RIVER FALLS JACKSON COUNTY HEALTH KROHN CLINIC/BLACK RIVER MEMORIAL HOSPITAL WATERTOWN DEPT. OF PUBLIC HEALTH JUNEAU COUNTY HEALTH KENOSHA COUNTY DIVISION OF HEALTH KEWAUNEE COUNTY HEALTH GHCE Eau Claire 16 49 3 6 3 20 14 0 0 4 2 5 3 1 61 ECFM Eau Claire 1 4 0 0 0 0 1 0 0 0 0 0 0 0 1 FDLC Fond du Lac 6 2 0 0 1 0 0 0 0 1 0 0 0 0 2 FRST Forest 7 1 1 0 0 0 0 0 1 0 0 2 0 1 5 FCPT Forest 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 GRCO Grant 2 3 0 0 0 0 0 0 0 0 0 0 0 0 0 RHCC Grant 3 2 0 0 0 0 1 0 0 0 1 0 0 0 2 GRNC Green 16 6 0 1 0 0 0 1 0 0 0 0 1 0 3 GRLA Green Lake 7 5 0 0 0 0 0 1 0 0 0 0 1 0 2 IOWA Iowa 9 4 0 0 2 0 0 1 0 0 0 1 0 0 4 HCNB Jackson 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 JACO Jackson 0 1 0 0 0 1 1 0 0 0 1 0 0 1 4 KRHN Jackson 22 13 1 0 3 1 1 0 2 1 0 0 2 0 11 WATE Jefferson 6 4 0 0 1 0 2 0 0 0 1 0 0 0 4 JUCO Juneau 0 1 1 1 0 1 1 2 0 1 0 1 0 0 8 KCHD Kenosha 26 26 0 1 0 1 3 3 2 0 2 2 1 1 16 KEWA Kewaunee 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 Page 23 of 30

SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 GUNDESEN HEALTH- LACROSSE GNDL La Crosse 0 11 1 0 0 0 1 0 0 0 0 1 0 0 3 HEALTH TRADITION HEALTH PLAN HTMA La Crosse 3 4 1 0 1 0 0 0 1 1 0 0 0 0 4 HO-CHUNK HEALTH LA CROSSE HCLX La Crosse 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 LA CROSSE COUNTY HEALTH LACR La Crosse 13 9 1 0 3 0 1 0 0 0 0 0 1 1 7 ASPIRUS LANGLADE HOSPITAL ALHO Langlade 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 LANGLADE COUNTY HEALTH LACO Langlade 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 LINCOLN COUNTY HEALTH LCHD Lincoln 7 1 0 3 0 1 0 0 0 0 0 0 1 0 5 MANITOWOC COUNTY HEALTH MTWC Manitowoc 5 13 1 1 2 0 1 2 2 1 0 0 0 1 11 MARATHON COUNTY HEALTH MACO Marathon 26 16 0 1 3 2 3 2 1 6 0 3 0 0 21 MARINETTE COUNTY HEALTH & MRNT Marinette 2 3 0 0 0 0 0 0 1 1 1 1 0 0 4 HUMAN SERVICES MARQUETTE COUNTY HEALTH MARQ Marquette 8 5 0 1 0 0 0 0 0 0 0 0 1 0 2 MENOMINEE TRIBAL CLINIC MENO Menominee 22 17 0 0 0 2 2 2 1 0 1 0 0 1 9 AURORA MIDWIFERY AND AMWC Milwaukee 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WELLNESS CENTER AURORA SINAI WOMENS CENTER AURS Milwaukee 49 49 3 9 8 6 5 5 7 3 4 6 4 1 61 AURORA SINAI MATERNAL FETAL ASPC Milwaukee 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 HIGH RISK PREGNANCY CENTER CATHOLIC CHARITIES - CCMK Milwaukee 4 8 0 0 0 0 1 0 1 1 0 0 0 0 3 MILWAUKEE CENTER FOR QUALITY CQCL Milwaukee 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 COMMUNITY LIFE CHILDREN'S COMMUNITY HEALTH CCHP Milwaukee 36 18 0 3 2 0 1 2 1 0 2 1 0 0 12 PLAN CITY OF CUDAHY HEALTH CUDA Milwaukee 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 Page 24 of 30

SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 CITY OF MILWAUKEE HEALTH MILW Milwaukee 6 4 0 0 0 0 0 0 0 0 0 0 0 0 0 COLUMBIA ST MARYS COSM Milwaukee 7 16 0 1 0 0 0 1 0 1 1 0 0 2 6 CREATIVE FAMILY SERVICES CRFS Milwaukee 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 FROEDTERT MATERNAL FETAL SOHW Milwaukee 0 6 2 1 3 0 1 6 3 2 3 0 1 0 22 CARE CENTER INDEPENDENT CARE HEALTH ICHP Milwaukee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PLAN LIFE ENHANCEMENT SUPPORT LESS Milwaukee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SERVICES FROEDTERT & THE MEDICAL LIFE Milwaukee 13 10 0 0 1 2 0 0 0 0 0 0 0 0 3 COLLEGE OF WISCONSIN OB/GYN LIFETIME MANAGED HEALTH SERVICES MHSV Milwaukee 33 21 1 2 0 0 0 1 0 1 1 1 0 2 9 MILWAUKEE CENTER FOR MKCI Milwaukee 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 INDEPENDENCE MILWAUKEE HEALTH SERVICES - MHSI Milwaukee 16 5 1 1 2 0 3 0 0 0 0 0 1 0 8 MLK MILWAUKEE WOMEN'S CARE MWCC Milwaukee 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 CENTER MOLINA HEALTHCARE MOLI Milwaukee 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 NEW CHOICES, LLC NEWC Milwaukee 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 NEXT DOOR FOUNDATION NXDF Milwaukee 2 1 1 1 0 0 0 1 0 0 0 0 0 0 3 OAK CREEK HEALTH OACR Milwaukee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PROGRESSIVE COMMUNITY WHAM Milwaukee 0 17 1 1 1 1 4 2 0 2 0 0 2 0 14 HEALTH CENTERS ROSALIE CENTER ROSA Milwaukee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SAFE N HIS ARMS SASP Milwaukee 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 ST. JOSEPH WOMEN'S WFSJ Milwaukee 96 87 4 6 7 2 6 4 4 3 2 2 4 2 46 OUTPATIENT CENTER UNITED COMMMUNITY CENTER UNCC Milwaukee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WEE CARE WIC CAPITOL WCWC Milwaukee 17 15 0 1 0 2 1 1 1 2 0 0 0 1 9 WEE CARE WIC NORTH WCWN Milwaukee 3 6 2 1 2 2 1 1 2 5 0 2 0 1 19 Page 25 of 30

SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 WEE CARE WIC TEUTONIA WCWT Milwaukee 9 8 0 0 0 0 0 0 1 0 1 1 0 2 5 WEST ALLIS HEALTH WAHD Milwaukee 45 44 5 3 4 5 2 3 4 4 0 1 0 2 33 WEST ALLIS WIC WAWI Milwaukee 0 0 0 0 0 5 6 2 4 3 3 4 5 4 36 WHEATON FRANCISCAN FAMILY WFGL Milwaukee 4 1 0 0 2 0 0 0 0 0 0 0 0 0 2 CARE CENTER GUNDERSEN HEALTH- TOMAH GNDT Monroe 0 7 1 1 0 0 2 0 3 1 0 5 0 3 16 HO-CHUNK HEALTH TOMAH HCTM Monroe 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MONROE COUNTY HEALTH MONR Monroe 12 31 2 2 2 1 3 4 0 2 1 1 3 1 22 SCENIC BLUFFS COMMUNITY SCBL Monroe 2 2 0 0 0 0 1 1 0 0 0 0 0 0 2 HEALTH CENTER CHILDRENS HOSPITAL CSWM Oneida 3 2 0 0 0 0 0 0 0 0 0 0 0 0 0 COMMUNITY SERVICES RHINELANDER ONEIDA COUNTY HEALTH ONDA Oneida 6 9 1 2 0 0 0 0 0 3 0 0 2 2 10 APPLETON CITY HEALTH APCI Outagamie 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 OUTAGAMIE COUNTY HEALTH & OUTC Outagamie 7 9 0 0 0 0 1 0 0 1 0 1 0 0 3 HUMAN SERVICES PEPIN COUNTY HEALTH PEPI Pepin 6 4 3 1 0 1 0 1 0 0 2 0 0 0 8 PIERCE COUNTY HEALTH PIER Pierce 3 7 0 0 0 0 0 0 0 0 0 0 0 0 0 POLK COUNTY HEALTH POCO Polk 30 37 3 3 5 0 1 1 2 7 0 4 3 4 33 MINISTRY MEDICAL GROUP RICE Portage 27 27 1 1 1 0 0 3 2 2 0 1 1 2 14 OB/GYN PRICE COUNTY HEALTH PRCO Price 3 2 0 0 0 1 0 0 0 0 0 0 2 0 3 CENTRAL RACINE COUNTY HEALTH CRHD Racine 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 CHILDREN'S HOSPITAL COMMUNITY SERVICES RACINE CHCS Racine 0 0 0 0 0 0 2 0 0 0 0 0 0 0 2 Page 26 of 30

SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 HEALTH AND NUTRITION SERVICE RHNS Racine 154 171 8 13 18 18 29 33 18 16 11 19 24 10 217 OF RACINE WHEATON FRANCISCAN - ALL WFAS Racine 15 9 1 1 0 1 0 0 3 2 1 2 0 1 12 SAINTS LAKEVIEW MEDICAL CENTER LKVW Rice Lake 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 RICHLAND COUNTY HEALTH RICH Richland 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 BELOIT CLINIC BELC Rock 26 24 0 6 0 2 2 1 1 0 0 9 0 2 23 ROCK COUNTY HEALTH ROCN Rock 0 7 1 1 1 1 0 1 2 0 3 0 0 1 11 NORTH ROCK COUNTY HEALTH ROCS Rock 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 SOUTH RUSK COUNTY HEALTH & HUMAN RUSK Rusk 6 7 0 1 0 2 0 1 0 0 0 0 0 0 4 SERVICES HO-CHUNK HOUSE OF WELLNESS- HCBO Sauk 0 4 0 0 1 0 0 0 0 0 0 0 0 0 1 BARABOO SAUK COUNTY HEALTH SAUK Sauk 13 16 0 0 2 0 0 0 0 1 0 2 3 0 8 SAUK PRAIRIE HEALTH SYSTEM SPMH Sauk 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 ESSENTIA HEALTH ESSN Sawyer 0 0 1 0 1 0 0 0 0 0 0 1 0 0 3 NORTH LAKES COMMUNITY CLINIC NLKC Sawyer 0 4 0 0 4 0 1 1 0 0 0 1 1 3 11 SAWYER COUNTY HEALTH SAWY Sawyer 4 14 1 1 0 0 0 0 0 1 0 2 0 0 5 HO-CHUNK HEALTH WITTENBERG HCWB Shawano 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 STOCKBRIDGE-MUNSEE HEALTH & STMU Shawano 7 1 0 0 0 0 0 0 0 0 0 0 0 0 0 WELLNESS CENTER SHEBOYGAN COUNTY HEALTH SHEB Sheboygan 13 12 0 1 1 1 0 1 1 1 0 0 0 0 6 ST. CROIX COUNTY DHHS STCR St. Croix 20 16 0 0 2 0 4 4 3 1 1 0 2 3 20 GUNDERSEN HEALTH-VIROQUA GNDV Vernon 0 4 0 0 2 1 0 0 0 0 0 1 1 1 6 VERNON COUNTY HEALTH VCHD Vernon 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 PETER CHRISTENSEN CENTER LACF Vilas 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 Page 27 of 30

SITE NAME SITE ID County 2013 2014 J F Mr A My Jn Jy Ag S O N D 2015 WALWORTH COUNTY HEALTH WALW Walworth 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 WASHINGTON COUNTY HEALTH WCHD Washington 0 0 0 0 1 5 3 3 1 1 0 2 0 0 16 ANTHEM BLUE CROSS BLUE CCOM Waukesha 18 8 0 0 0 0 1 1 0 1 0 0 0 0 3 SHIELD MEDICAID AUROROA WILKINSON MEDICAL AWCS Waukesha 14 13 0 0 1 2 1 1 1 2 0 0 1 2 11 CENTER-SUMMIT EVANGELICAL CHILD & FAMILY ECFA Waukesha 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 AGENCY MORELAND OB/GYN ASSOCIATES MORE Waukesha 13 6 0 0 1 2 0 1 0 1 1 0 0 1 7 SAFE BABIES HEALTHY FAMILIES SBHF Waukesha 2 4 0 0 0 0 0 0 0 2 2 0 0 0 4 WAUKESHA COUNTY PUBLIC WAUK Waukesha 10 11 0 0 1 0 0 1 0 0 1 0 1 0 4 HEALTH DIVISION WAUKESHA FAMILY PRACTICE WFPC Waukesha 3 9 0 0 2 0 2 0 0 0 0 0 0 0 4 CENTER WAUPACA COUNTY HEALTH WTFC Waupaca 16 8 0 0 0 0 0 0 0 1 0 1 0 0 2 FAMILY HEALTH/LA CLINICA FHLC Waushara 3 0 0 0 0 0 0 0 1 0 0 0 0 0 1 WAUSHARA COUNTY HEALTH WACO Waushara 7 6 0 1 1 2 0 0 0 0 0 1 0 1 6 MENASHA CITY PUBLIC HEALTH MPHD Winnebago 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WINNEBAGO COUNTY HEALTH WINN Winnebago 2 9 0 0 1 0 2 0 1 0 2 0 0 0 6 DEPT HO-CHUNK HEALTH CHAK-HAH- HCNH Wood 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CHEE MARSHFIELD CLINIC OB/GYN MCMF Wood 19 26 2 0 3 0 3 1 3 0 0 6 0 3 21 TOTAL 1478 1465 77 99 129 118 142 122 101 110 69 113 93 90 1263 Page 28 of 30

7. Appendix B: Refresher Training Menu

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